Download LETTER OF MEDICAL NECESSITY

LETTER OF MEDICAL NECESSITY
DATE:
TO:
FROM:
PATIENT:
INSURANCE ID:
SUBSCRIBER:
DOB:
GROUP NO:
To Whom It May Concern:
XYZ is a _______ year old patient with a rare disorder (or inborn error of metabolism) called Methylmalonic Acidemia
(MMA)/Propionic Acidemia (PA). This disorder is a type of ___________________ whereby the affected individual is
unable to _____________________. The purpose of this letter is to explain the medical necessity of a treatment I am
ordering for this patient which is imperative in the management of this condition. It is a specialized medical food called
MMA/PA gel.
The accepted standards of care to treat this disorder consist of a diet low or void of the amino acid(s) methionine,
threonine and valine. Therefore, adequate protein intake and utilization is not possible without the use of a protein
substitute/specialized medical food. Without adequate protein intake, the body __________________________ and this
can cause ________________________. Without proper medical treatment, XYZ is at risk for _______________ and
other negative symptoms from his/her disease. This could lead to (hospital admissions, expensive diagnostic testing and
critical consequences).
In XYZ’s situation we have noted ( _____ labs up/down, weight loss, feeding issues, behavioral issues, taste burnout
with current metabolic supplement/formula, inability to meet caloric needs, muscle wasting, fullness from certain
formulas or those that must be taken in addition to food adding volume, other documented issues). This product is
needed to assist in: ( ________ meeting calorie needs, meeting overall protein needs, prevent vitamin/mineral
deficiencies, reduce potential complications of this disorder, decrease need for medication/other treatments, prevent
more expensive treatment options such as: ___________________). The use of prescription specialized medical foods
has shown positive outcomes in evidenced-based research.
MMA/PA gel is a powdered medical food that is methionine, threonine and valine free, and provides the necessary
mixture of amino acids, carbohydrates, minerals, trace elements and vitamins to meet XYZ’s daily nutritional needs. It is
manufactured by Vitaflo USA, LLC (1-888-VITAFLO). HCPCS is B4162. Reimbursement code: 50600-0515-23.
The attached prescription is for XYZ to take _______ packets per day in order to meet his/her protein (and calorie)
intake needs. This patient has already sampled MMA/PA gel and it has been tolerated and accepted well.
I appreciate your consideration with this request. Your authorization of the prescription will provide this patient the
treatment needed to improve his/her medical situation, resulting in an overall cost savings to your company. Please feel
free to contact me if you have additional questions.
Sincerely,
Name of Physician